COVID‐19‐associated pityriasis rosea in children: Case report and literature review

Abstract Skin lesions are one of the Coronavirus disease 2019 (COVID‐19) symptoms. Pityriasis rosea (PR) is a mucocutaneous manifestation that can occur following virus infections. Most of the PR lesions after COVID‐19 infection were reported in adults. Herein, we report a child with PR lesions, and a literature review on 5 other case reports in children.


| INTRODUCTION
The Coronavirus disease 2019 (COVID-19) symptoms are variable; but often include fever, cough, and fatigue. 1 Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection can also present with cutaneous manifestations classified into two major categories: inflammatory and vasculopathy lesions.
The clinical presentation, course, outcome, and cutaneous manifestations of SARS-CoV-2 infection in children usually differ from adults. 2 One uncommon COVID-19-related mucocutaneous manifestation is pityriasis rosea (PR) 2 ; typically presenting with a single, erythematous plaque followed by a secondary eruption with lesions on the cleavage lines of the trunk (configuration of a "Christmas tree"). 3 As we reviewed, most of the reported cases of PR lesions after COVID infection are adults 4,5 and PR is quite rare in children under 10 years old. 6 Herein, we report a case of PR during the post-COVID period in a 7-year-old child.

| CASE PRESENTATION
A 7-year-old girl presented with erythematous scaly patches on the anterior and posterior of the trunk, in association with a larger herald patch on the back ( Figure 1). The patient had no symptoms other than itching at this period. Two weeks before the initiation of cutaneous lesions, she suffered from cough, sore throat, rhinorrhea, and mild diarrhea. She had no remarkable past medical history. At the same time, the patient and her family had the same symptoms with positive RT-PCR for SARS-CoV-2 infection. Based on her clinical presentations and history of confirmed COVID-19, a diagnosis of COVID-19-associated Pityriasis rosea was made. Topical corticosteroids and systemic antihistamines were started for treating pruritic patches. Clinical improvement appeared 2 weeks after the initiation of conservative treatment.

| DISCUSSION
We reported a 7-year-old girl with SARS-CoV-2-related PR during the post-infection period.
The exact etiopathogenesis of PR is still unknown; but in many cases, before the onset of PR, there are episodes of upper respiratory tract infections, that highlight the viral etiology of this condition. 7 Viruses, vaccination, and drugs have been implicated as the cause of PR. The most important viruses are Human Herpesvirus (HHV)-6 and HHV-7. These viruses may also interact with each other, explaining recurrences and atypical presentations. 8 Pityriasis rosea and PR-like eruptions have been reported following other viruses vaccines like influenza, poliomyelitis, yellow fever, hepatitis A, rabies, and Japanese encephalitis. 9 It seems that COVID-19 can be a trigger for PR. In COVID-19 cases, the skin lesions appear due to a large invasion of pro-inflammatory cytokines and microthrombosis on the skin. 6 Overall, SARS-CoV-2 may have triggered a chain viral reaction. SARS-CoV-2 may have played a trans-activating role; triggering HHV-6, HHV-7, and Epstein-Barr virus (EBV) reactivation and causing cutaneous PR-like lesions. EBV concurrent systemic reactivations have been detected in a patient with PR and COVID-19. 10 Also, the psychological stress linked to the pandemic and the immunosuppression associated with SARS-CoV-2 infection may enable the reactivation of latent viral infections. 8 Dermatologic symptoms of COVID, like other symptoms, are less severe in children than in adults. 11 PR lesions in adults can present as erythematous plaques or few patches disseminating after a few days to a wider surface of the body. [5][6][7] Also these lesions in reported adults mostly last more than 2 weeks 4-6,12 ; which is a long time compared with reported children. 11,13,14 The pruritic lesions were treated conservatively with an antihistamine or topical corticosteroids in adults 4-7,12 and children. 10,11 To date, five cases of PR and PR-like eruption related to COVID-19 in children have been published (Table 1). 10,11,[13][14][15] In these cases, the patient's ages were between 5 and 16 years old; three of them had mild symptoms of COVID-19 and had close contact with confirmed cases. 10,11,15 All of them had erythematous scaly patches on the trunk and extremities, which lasted for 10-14 days. They had conservative treatment; but only in one case, systemic steroid therapy was considered. 13 F I G U R E 1 COVID-19 associated Pityriasis rosea-like eruptions. Several erythematosquamous patches and plaques are located on the trunk of a child (A). Larger, slightly raised, scaly plaque on the back (B).